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RD1 1 8  B382  Present  status  of  pi 


Beck 

♦..Present  status  of  plastic  surgery  about 
the  ear,  face  and  neck. 


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PRESENT  STATUS  OF  PLASTIC  SURGERY  ABOUT  THE 
EAR,  FACE  AND  NECK. 


DR.  JOS.  C.  BECK,  CHICAGO. 


(Reprint  from  The  Laryngoscope,  St.  Louis,  May,  1920.) 


PRESENT  STATUS  OF  PLASTIC  SURGERY  ABOUT  THE 
EAR,  FACE  AND  NECK. 


DR.  JOS.  C.  BECK,  CHICAGO. 


(Reprint  from  The  Laeyngoscope,  St.  Louis,  May.  1920.) 


PRESENT  STATUS  OF  PLASTIC  SURGERY  ABOUT  THE 
EAR,  FACE  AND   NECK. 

Dr.  Jos.  C.  Beck,  Chicago. 

Division ; 

1.     As  results  of  war  injuries. 
2^.     In  civil  life. 

a.  Prom  diseases. 

b.  Injuries. 

c.  Congenital. 

d.  Cosmetic. 

e.  Psychic  or  imaginary. 

I.  Plastics  in  War  Injuries:  Owing  to  the  results  from  severe 
wounds  and  diseases  of  so  many  men  in  the  World's  War,  there 
was  and  is  a  great  demand  for  physicians  and  surgeons  to  correct 
and  reconstruct  these  defects.  Cases  requiring  plastic  surgery  about 
the  head,  face  and  neck,  make  up  a  very  large  portion,  although 
comparatively  a  small  proportion  of  Americans  as  to  those  of  the 
other  nations  who  were  in  the  fight  since  1914  and  1915. 

During  the  years  of  1915-16-17  I  presented  papers  before  the 
Chicago  Odontographic  Society,  Illinois  Dental,  Chicago  Oto-Laryn- 
gologic  Society,  the  American  Academy  of  Ophthalmology  and  Oto- 
Laryngology,  Dominion  Medical  Association  and  Alabama  State 
Association  in  which  I  urged  oto-laryngologists,  opthalmologists  and 
oral  surgeons  of  America  to  turn  their  attention  to  the  training  of 
plastic  surgery  in  order  that  when  the  time  came  (I  was  certain  it 
would  come)  they  would  be  ready  to  do  their  part. 

In  1917,  when  the  United  States  entered  the  war,  the  Surgeon 
General  in  his  organization  of  the  Division  of  the  Head,  made  pro- 


4  be;ck:   present  status  of  plastic  surgery. 

vision  for  a  department  of  Plastic  and  Oral  Surgery  under  the  com- 
mand of  Dr.  Yilray  P.  Blair,  of  St.  L/)uis.  He  very  ably  and 
rapidly  developed  a  school  and  classes  for  the  education  of  men 
who  would  be  emplo3^ed  in  the  service  along  these  lines.  I  had 
the  great  pleasure  and  privilege  of  teaching  in  some  of  these  classes 
as  to  what  I  knew  of  reconstructive  work  from  ray  previous  experi- 
ence in  civil  life  as  well  as  from  reading,  and  personal  communica- 
tion with  English,  French,  Italian,  Austrian  and  German  surgeons 
as  to  their  experience  in  war  plastics  since  1914.  In  these  cases  I 
was  struck  by  the  absence  of  men  from  the  oto-laryngological  field, 
for  I  expected  and  hoped,  they  would  be  the  first  to  enter  this 
service.  When  I  was  asked  by  the  department  at  Washington  to 
recommend  some  men  whom  I  knew  and  thought  would  like  this 
special  assignment,  I  received  some  of  the  most  uncomplimentary 
replies,  as  well  as  poor  excuses  why  they  could  not  serve.  I  men- 
tion this  fact  advisedly  at  the  present  time,  because  it  seems  as 
though  only  that  type  of  plastic  surgery  which  has  to  do  with  cos- 
metics or  beautifying  as,  for  instance,  taking  off  of  a  hump  or  filling 
up  a  saddle  defect  of  the  nose,  and  which  really  calls  for  very  little 
surgical  skill,  appears  to  interest  some  oto-laryngologists. 

There  are  two  periods  during  which  plastic  work  is  performed, 
namely,  immediately  after  injury  and  secondarily  or  later.  In  the 
immediate  operations,  one  attempts  to  bring  the  parts  together  as 
nearly  normal  as  possible,  both  from  the  cosmetic  side  as  well  as 
functionally.  This  is  very  frequently  not  feasible  by  virtue  of  the 
fact  that  the  patient's  general  condition  wnll  not  permit  operating 
upon  him  or,  the  tissues  locally  are  not  fit  for  operation,  as  f.  i., 
foreign  bodies,  infections,  lack  of  circulation,  etc.  In  such  cases 
one  v^dll  frequently  defer  the  work  for  a  secondary  operation.  Sec- 
ondary operations  are  also  performed  to  improve  previously  cor- 
rected parts.  This  is  rather  the  rule  and  it  is  not  uncommon  to 
have  a  case  in  which  as  many  as  fifteen  operations  are  performed 
oefore  a  sastisfactory  physiologic  and  cosmetic  result  is  obtained. 

In  the  discussion  of  the  various  forms  of  war  injuries  about  the 
head,  face  and  neck  requiring  plastic  surger\%  it  is  not  possible  to 
classify  them  on  account  of  their  multiplicity  of  conditions,  conse- 
quently no  specific  rules  can  be  made  as  to  their  management :  in 
other  words,  every  case  is  a  law  unto  itself.  The  degree  of  the 
injury,  the  condition  of  the  tissues,  locally,  and  the  general  condi- 


be;ck  :    pre;se;nt  status  of  plastic  surgery.  5 

tion  of  the  patient,  are  of  importance  as  to  the  result  that  may  be 
expected. 

In  my  own  service  at  the  American  Red  Cross  Hospital  No.  113> 
at  Cognac,  France,  and  Czecho-Slovak  Red  Cross  Hospital  at 
Prague,  Bohemia,  where  I  had  charge  of  general  as  well  as  special 
work,  there  came  under  my  care  336  cases  of  plastic  surgery 
of  which  89  cases  were  of  head,  face  and  neck  injuries.  These 
were  divided  into — 

1.  Scalp  and  skull  plastics,  including  upper  part  of  orbit  and 
upper  eyelid. 

2.  External  nose,  including  lower  eyelid  or  upper  lip. 

3.  Upper  maxilla  including  external  nose,  upper  lip  or  lower 
eyelid. 

4.  Inferior  maxilla,  including  lower  lip. 

5.  Both  upper  and  lower  maxilla  including  one  or  both  lips. 

6.  Lower  maxilla  and  neck  wound  with  or  without  perforation 
of  the  larynx,  trachea  or  esophagus. 

7.  Neck  wound  with  or  without  perforation  of  the  larynx, 
trachea  or  esophagus. 

8.  External  ear, 

9.  Compound  in  which  more  than  one  of  the  above  mentioned 
injuries  were  present. 

These  divisions  could  be  further  sub-divided  as  f.  i.  Severance 
of  large  blood  vessels  and  nerves,  etc.,  but  for  a  simple  classifica- 
tion and  easy  indexing  the  above  division  served  me  very  well, 
and  in  my  observation  of  other  surgeons'  services,  T  found  that 
this  same  classification  would  have  answered  the  practical  purpose. 

The  immediate  result  from  operations  on  these  cases  in  my 
service,  was  far  from  satisfactory,  because  they  were  or  had  become 
infected  and  practically  every  case  demanded  one  or  more  secondary 
operations.  The  same  was  true  in  my  observation  of  other  work. 
It  is  very  regrettable  that  in  my  service  as  well  as  that  of  many 
other  men,  the  results  of  the  secondary  operations  could  not  be 
followed  up,  owing  to  the  fact  of  the  patients  being  transferred 
to  their  respective  homes,  for  further  observation  or  operations.. 

There  were,  however,  many  places  where  I  had  the  pleasure  of 
observing  cases  that  had  been  operated  upon  all  the  way  from  one 
day  to  four  and  one-half  years  before  as  well  as  seeing  different 


t)  BECK  :     PRESENT   STATUS   OF   PLASTIC   SURGERY. 

operators  and  many  operations,  so  that  I  have  formed  a  fair  opinion 
as  to  results  and  selection  of  operations.  While  there  has  not  de- 
veloped anything  remarkable  or  particularly  new  in  plastic  surgery 
m  this  war,  there  can  be  no  question  that  much  was  learned  from 
the  large  amount  of  material  which  the  war  furnished.  I  shall  not 
attempt  to  go  into  great  detail  in  describing  operations,  but  will 
:llastrate  some  of  the  wo-k  [  have  observed  and  make  commer^ts 
thereon. 


Fig-.    I.      Reconstruction    of   nose    (Eng-lish). 


Owing  to  the  peculiar  service  that  I  had,  I  was  enabled  to  visit 
many  military-  hospitals  in  the  Allied  countries,  particularly  in 
France,  Italy  and  England  and,  therefore,  had  a  great  opportunity 
of  seeing  the  good  as  well  as  the  bad.  I  have  selected  some  of  the 
procedures  and  have  taken  the  liberty  of  illustrating  them  not  with 
any  idea  of  publishing  other  men's  work  ahead  of  their  original 
articles,  nor  that  anyone,  especially  those  not  familiar  with  plastic 
M^ork,  shall  be  able  to  perform  such  operations,  but  merely  to  report 
some  of  the  interesting  work  I  have  seen  over  there. 

Fig.  I.  Nasal  Defects:  The  following  four  illustrations  show 
steps  of  an  operation  that  appeared  to  give  better  results  than  any 


be;ck:   present  status  of  plastic  surgery. 


^  V .  - ,  ,a:  .v^  V  rl/^  /  - '  -/  ^^>-x,  fore  head 


/..^/^^^c^/i'i^^^:^.^^ 


defect 


door 
s  cover- 
nose 
defect 


defect 


4v|/i5ted 
(pedicle 


forehead 
flap  over 
nose 


Fig.  I. 


8  beck:   present  status  oe  plastic  surgery. 

other,  when  the  defect  was  confined  to  the  lower  portion  of  the 
nose.  I  had  the  pleasure  of  seeing  cases  operated  upon  by  this 
method  as  presented  in  London  to  the  British  Medical  Association 
as  well  as  at  Sidcop,  Queens'  Hospital,  Canadian,  Division,  under 
the  head  of  Dr.  Waldron.  The  work  done  at  that  hospital  under 
the  direction  of  Dr.  Gillis  was  excellent  and  his  publication  (text- 
book) should  be  seen  by  all  who  are  interested  in  the  subject. 

Pig.  II.     Nasal  Defects:    The  following  three  illustrations  shov/ 
particularly  LaMaitre's  operative  procedures  as  carried  out  at  the 


Wolf  graft 


pedicle 
(turned 
bacK 


Pig-. 


hospital  at  Vichy  and  he  prefers  it  to  any  other  procedure  in  defects 
particularly  suitable  for  it.  At  times  there  is  planted  a  piece  of 
bone  or  cartilage  under  the  forehead  flap  several  weeks  before  the 
latter  is  transplanted.  One  very  interesting  point  in  Le  Maitre's 
operation,  is  the  fact  that  it  is  a  one-step  procedure.  There  are  so 
many  other  important  and  interesting  facts  about  this  and  many 
other  of  his  operations  that  would  be  of  worth  to  describe  here,  but 
this  is  not  the  purpose  of  my  paper.  Consequently  the  writer 
would  suggest  the  careful  reading  Le  Maitre's  plastic  work  which  is 
to  appear  very  soon  in  the  Annals  of  Otology,  Rhinology  and 
Laryngology,  St.  Louis. 


BECK  :     PRESENT   STATUS   OF    PLASTIC   SURGERY. 


cover 
flap 


nasa 
defect 


10 


beck:   present  status  oe  plastic  surgery. 


defect 
closed 


puckennij 
of  flap 
resected 


Fig.  II. 


lip  defect 


double 
pedicle  flap 


Fig.  III.     Reconstruction  of  upper  lip    (French). 


be;ck:  present  status  oe  plastic  surgery. 


11 


Fig.  III.  Upper  Lip  Defects:  The  following  three  illustrations 
show  a  very  novel  and  satisfactory  procedure  employed  by  Sibelo 
and  his  associates  at  the  Valde  Gras  Hospital,  in  Paris.  Of  course, 
it  is  only  applicable  to  males. 

closure  of  scalp 
>  ^        defect 


double 

pedicle  flap 
in  place  of  lip 


Fig.  III. 

Fig.  IV.  Lower  law  and  Lip  Defect:  The  following  three 
illustrations  show  how  easily  very  large  double  pedicle  skin  flaps 
can  be  taken  from   the   neck  without  any  great   amount  of   scar 


12 


BECK;     PRESENT   STATUS   OF   PLASTIC   SURGERY. 


formation  resulting,  not  functional  disturbances.  It  enables  one  tc 
do  subsequent  bone  implantation  for  lower  mandible  reconstruction. 
Both  the  English  and  the  French  make  use  of  similar  technic.  The 
operations  on  the  lower  jaw  as  suggested  by  Cole  are  perhaps  the 
best  that  were  done  anywhere  in  the  world.  The  pedicle  graft 
appears  to  be  more  fa^'ored  than  transplant.  La  Maitre  lays  much 
stress  on  regeneration  of  the  periosteum  in  obtaining  a  solid  jaw. 
whereas  the  English,  Italians  and  Americans  do  not  take  much  stock 
in  it. 


Fig.  IV.     Reconstruction  of  lower  lip    (French  and  English). 


Fig.  V.  Lower  Jaw  and  Lip  Defect:  The  following  three 
illustrations  show  a  very  novel  method  of  reconstruction  and  I 
believe  offer  a  much  better  ultimate  result  than  just  shown.  The 
rolled-up  mass  of  skin,  etc.,  is  left  hanging  by  its  pedicle  for  several 
v.^eeks,  being  placed  into  defect  during  the  day,  aiding  speaking  and 
eating.  It  is  held  in  place  by  a  bandage  when  it  is  sutured  in  place. 
I  have  seen  a  number  of  these  cases  in  Prague,  and  also  in  Paris. 

Fig.  VI  and  VIL  Bone  and  Cartilage  Transplants:  In  order 
to  stiffen  parts  in  reconstruction  of  nose,  jaws,  etc.,  the  English 


bi;ck:    present  status  op  plastic  surgery. 


13 


Fig.  IV. 


14 


B^CK:     PRESENT  STATUS  OE  PLASTIC   SURGERY. 


have  employed  the  crest  of  the  illium  in  preference  to  the  anterior 
border  of  the  tibia  (Rysdon  said  that  they  had  several  cases  of  frac- 
tures of  the  tibia  following  removal  of  the  parts  of  same).  My 
idea  is  that  it  was  probably  due  to  a  secondary  rarifying  osteitis, 
causing  the  fracture  rather  than  that  too  much  was  removed.  In 
the  use  of  cartilage  transplants  a  very  practical  and  novel  idea  is 
the  resection  of  several  pieces  of  costal  cartilage  but  only  perhaps 


flap  rolled   up 


rolled  up  flap 
in  place  of 
jaw  defect 


Reconstruction     of    lowet^  jaw 
(SERMA,N     me-thod)      ! 

Fig.  V. 


making  use  of  one  piece.  The  remaining  pieces  are  placed  right 
under  the  true  layer  of  skin  in  close  proximity  to  the  incision  which 
is  closed.  Then  whenever  another  piece  of  cartilage  is  required  in 
the  same  or  another  case,  one  can  very  easily  open  the  mcision  under 
local  ansthesia  and  remove  a  piece  from  the  storage  place. 

Fig.  VIII.  The  following  two  illustrations  show  a  very  practical 
flap  for  external  ear  construction  employed  by  the  English.  The 
neck  flap  is  doubled  up  upon  itself  along  its  length  with  the  skin 
outwards  and  the  end  sutured  into  the  ear  defect,  subsequently  the 
pedicle  is  out  and  this  tube  like  flap  is  shaped  into  an  auricle. 


beck:   present  status  oe  plastic  surgery. 


15 


Operation  for  reconstruction 
of   the   lower  jaw 

(ENGLISH) 


cartilage 


Cartilage    Storage 

(ENGLISH) 


Fig-.  VI. 


Fig.  VII. 


Fig.  VIII.     Tubular  flap.     External   ear  reconstruction   (English). 


16 


beck:   present  status  of  plastic  surgery. 


There  are  a  number  of  other  procedures  that  have  been  developed, 
which  are  of  interest  especially  in  Maxillo-facial  plastics.  I  have 
reference  to  the  various  appliances,  but  there  too  each  case  requires 
its  particular  constructed  apparatus.  In  this  connection,  La  Maitre's 
work  shop  was  the  best  I  ever  saw,  it  demonstrated  the  importance 
of  the  association  of  a  dentist,  mechanician  and  plastic  surgeon. 

One  striking  feature  to  me  was  the  rarity  with  which  the  Italian 
operation  was  performed.     Only  in  Italy  have  I  seen  cases  operated 


by  that  method  and  very  few  at  that.  On  the  other  hand,  consid- 
erable use  of  Wolf  and  Thiersch  grafts  were  being  made.  The 
keeping  in  position  of  these  grafts  (Stent)  by  the  modeling  com- 
pound in  the  orbital  and  oral  cavities  give  good  results.  The  open 
wound  dressing  was  another  departure  and  less  infection  of  milder 
character  was  noticeable  in  consequence. 

One  of  the  most  important  factors  in  the  successful  outcome  of 
plastic  operations,  is  not  to  operate  too  soon  after  the  primary  or 
previously   performed   secondary  operation.     This   fact  was   thor- 


BECK:    pre;se;nt  status  or  plastic  surgery.  17 

oughly  exemplified  over  there  in  that  the  intermediary  waiting 
period  was  usually  from  three  to  six  months.  In  civil  life  it  is 
most  difficult  to  put  off  patients  who  are  constantly  urging  to  have 
the  work  finished.  Operating  too  early  after  a  previous  operation 
has  caused  several  defeats  in  my  practice. 

In  regard  to  my  observation  in  plastic  work  in  American  hospitals 
abroad  I  am  not  able  to  say  very  much,  simply  because  there  were 
not  many  cases  and  too  early  to  judge. 

At  the  American  Red  Cross  Hospital  No.  1,  at  Nuille,  France, 
I  saw  about  two  hundred  maxillo-facial  and  other  head  plastics  in 
charge  of  Dr.  Coughland  who  made  use  of  methods  entirely  in- 
dividual. 

Considerable  stress  was  laid  upon  the  use  of  Carrell  Dakin's  solu- 
l:ion  and  the  bacterial  control  before  operation  was  undertaken. 

At  the  Base  Hospital  No.  115,  at  Vichy,  I  was  disappointed  not 
to  find  any  face,  head  or  jaw  plastics,  only  a  few  lid  cases  in  charge 
of  Dr.  Francis.  In  this  country  I  have  seen  recently  some  of  the 
cases  that  were  sent  back  for  further  work  at  Jefferson  Barracks, 
Ft.  McHenry  and  Walter  Reed. 

Dr.  Blair,  who  was  in  charge  at  Jefferson  Barracks,  was  kind 
'enough  to  show  me  some  of  his  cases  as  well  as  operate  a  most 
difficult  case.  His  development  of  the  technic  in  that  particular 
case  the  day  before  operation,  exemplified  one  of  the  characteristics 
of  a  good  plastic  surgeon,  namely  patience.  Casts,  photographs  and 
artistic  illustrations  were  shown  in  abundance  and  should  be  of  con- 
siderable value  when  published. 

Dr.  Schaeffer  at  Ft.  McHenry  was  equally  desirous  of  showing 
me  all  he  had  and  I  should  say  his  operating  technic,  cases,  demon- 
strations, as  well  as  their  records,  casts,  models,  photographs,  etc., 
would  stand  criticism  as  good  work. 

Dr.  Ivy,  in  charge  at  Walter  Reed,  had  the  advantage  of  the 
previous  two  gentlemen,  in  that  the  equipment,  artists,  etc.,  ap- 
peared to  be  of  a  higher  standard  and  therefore  could  demonstrate 
to  better  advantage.  Some  of  the  most  interesting  cases  were  shown 
to  me  and  an  operation  on  the  lower  jaw  was  performed  in  the 
classical  Cole  method  of  a  pedicle  graft.  Particularly  valuable  was 
my  observation  in  the  Dental  Mechanics  laboratory,  where  the  vari- 
ous appliances  were  made  by  what  appeared  experts  and  reminded 
me  of  La  Maitre's  work  shop. 

The  results  from  the  surgical  standpoint,  I  believe,  cannot  be 
improved  upon,  but  cosmetically  and  functionally  there  is  much  to 


18  beck:   present  status  oe  plastic  surgery. 

be  wished  for.  This  I  say  from  my  observations  on  cases  which 
1  have  observed  that  have  come  under  my  care  at  the  Marine  and 
Public  Health  Hospital  in  Chicago  for  further  operations.  Most 
of  these  cases  have  never  seen  the  three  hospitals  nor  surgeons  just 
mentioned  but  were  cases  that  were  taken  care  of  at  regular  base 
hospitals  over  there  and  sent  back  much  earlier  than  these  mentioned 
at  Jeiierson  Barracks,  McHenry  and  Walter  Reed. 

Finally  there  has  developed  this  fact,  that  practically  in  no  in- 
stance was  a  soldier  willing  to  accept  an  artificial  ear,  nose,  jaw  or 
part  of  face  instead  of  a  reconstructed  one  by  operation  though  the 
prothesis  was  much  better  looking. 

2.  Plastics  ill  Civil  Life.  A.  "Folloiving  Disease'':  Follow- 
ing diseases  such  as  syphilis  and  tuberculosis  are  responsible  for  the 
largest  number,  but  with  the  present  mode  of  treatment  by  salvar- 
san  in  lues  and  radiotherapy  in  tuberculosis  there  will  be  a  marked 
decrease  in  their  production.  The  treatment  scar  formation  as  an 
end  result  of  a  healed  out  luetic  nose  gives  the  greatest  difficulty 
in  the  healing  of  the  parts  after  operation.  It  is  therefore  best  to 
remove  as  much  as  possible  of  this  scar  tissue  even  the  defect  made 
greater  by  so  doing.  Although  one  considers  the  case  cured  of 
syphilis  with  a  negative  Wasserman  for  some  time.  I  have  found 
the  giving  of  salvarsan  at  the  time  or  just  before  the  operation,  to 
be  of  value  in  the  healing  of  the  parts. 

There  is  one  operation  following  the  disease  of  atrophic  rhinitis 
that  I  wish  to  describe  very  briefly  which  is  a  plastic  for  therapeutic 
of  physiologic  purposes.  I  have  already  reported  on  the  use  of 
fascia  lata  implantation  for  this  purpose,  but  now  I  employ  only 
septum,  both  cartilage  and  bone,  obtained  from  a  freshly  submucous 
resected  septum,  just  preceding  the  operation. 

The  technic  is  very  simple.  One  performs  a  thorough  dissection 
of  muco-periostium  and  perichondrium  as  in  an  extensive  submucous 
resection,  then  break  through  the  cartilage  and  bone  at  several 
places.  This  is  done  for  the  purpose  of  permitting  circulation  be- 
tween the  two  layers  of  perichondrium  and  peristeum,  thus  improv- 
ing the  nourishment  of  the  implants.  The  just  previously  resected 
septum  (having  tested  the  blood  for  proper  grouping  of  donor  and 
recipient)  is  now  cut  into  small  pieces  and  put  between  the  muco- 
periosteal  and  perichondrium  flaps,  taking  great  care  not  to  allow 
contact  with  the  distention,  at  the  inferior  meatus.  The  incision  is 
closed  by  a  stitch  and  sealed  with  collodion. 


beck:    present  status  of  plastic  surgery.  19 

Lupus  or  tuberculosis,  which  are  much  more  rare,  will  cause  de- 
formities of  the  tip  of  the  nose  or  the  lae.  Since  the  use  of  x-ray 
and  radium  treatment  has  substituted  the  surgical  attacks,  the  sub- 
sequent plastic  results  are  far  more  satisfactory,  owing  to  less  fre- 
quent recurrences  of  the  disease. 

Malignant  growth  particularly  epitheHum  both  of  ears,  external 
nasal,  eye  lids  and  lips  make  up  quite  a  number  of  cases  that  require 
plastic  operations  subsequent  to  x-ray,  radium  or  surgical  interven- 
tion. 

(b)  Traumatic.  These  have  increased  very  much  in  the  past 
few  years  due  to  automobile  accidents,  but  on  the  other  hand  have 
decreased  considerably  from  occupational  causes.  The  latter  is  due 
to  the  fact  that  manufacturing  plants  are  more  careful  in  the  fitting 
out  of  shops  with  safety  devices  and  there  are  special  Insurance 
Boards  who  look  after  these  matters,  in  order  to  safeguard  both  em- 
ployer, employe  and  insurance  company.  There  is  no  possibility 
of  classifying  cases  of  injury  which  are  the  same  as  those  occurring 
in  war  times  and  every  case  is  a  law  unto  itself.  Obe  type  of  trau- 
matic deformity  has  interested  me  particularly,  namely  facial  pa- 
ralysis, and  I  shall  describe  same  more  in  detail  with  report  of  some 
cases. 

c.  Congenital  Defects.  Three  types  of  deformities  have  pre- 
sented themselves  to  me  more  frequently  than  any  other,  and  these 
are: 

1.  Total  or  partial  loss  of  external  ears. 

2.  Marked  shortening  or  absence  of  calomella  with  absence  of 
septal  cartilage. 

3.  Cleft  palate  and  harelip. 

1.  In  the  correction  of  the  "external  ear"  I  have  now  four  cases 
under  treatment  of  reconstruction  and  will  very  briefly  describe 
them,  because,  thus  far,  the  subject  has  not  received  the  attention 
that  it  should.  The  first  illustration.  Fig.  IX,  shows  the  cases  before 
anything  had  been  done.  They  are  from  2^  years  to  6  years  of 
age.  One  is  a  bilateral  case.  X-ray  of  mastoid  shows  in  each  case 
the  evidence  of  a  middle  ear  and  outline  of  the  internal  ear.  Rota- 
tion test  shows  functioning  vestibular  apparatus  in  three,  however, 
duration  of  nystagmus  much  reduced  in  deficient  ear.  Attempts 
made  in  the  younger  children  as  to  the  ability  to  hear  by  the  aid  of 
the  noise  apparatus  was  not  successful  because  all  these  children 
refused  to  permit  the  buzzer  in  their  ear.    The  oldest  (girl  6  years) 


•20 


BECK  :     PRESENT  STATUS  OE   PLASTIC   SURGERY. 


Fig.  IX. 


Fig-.  IX. 


Fig-.  IX. 


Fig.  IX. 


BECK:    prese:nt  status  of  plastic  surgery. 


31 


did  permit  it,  and  I  found  that  she  did  not  hear  on  the  defective 
side,  although  there  was  a  nystagmus  on  rotation  present. 

The  second  illustration,  Fig  X,  shows  the  children  after  one  or 
more  operation,  of  adding  tissue  by  pedicle  flaps  from  the  m.astoid 
and  neck  regions.  Cartilage  transplants  will  he  employed  when  the 
soft  parts  of  this  ear  is  finished,  rather  than  immediately,  because 
from  my  previous  experiences  with  the  shrinking  began  ir  crumbled 
the  cartilage  out  of  shape.  I  shall  make  use  of  costal  cartilage  from 
mother  or  father  (depending  upon  the  result  of  the  titrating  test  of 
blood  of  donor  as  well  as  recipient  of  the  tissue).  In  the  past  year 
]  have  made  use  of  resected  septum  cartilage  and  bone  of  other 


Pig-.  X. 

patients  proving  up  this  above  mentioned  grouping  by  the  blood 
test. 

2.  Congenital  absence  of  part  or  all  of  the  septal  cartilage,  caus- 
ing the  squashed  tip  of  the  nose  with  a  very  short  collomella.  This 
in  turn  causes  the  greatest  diameter  of  the  nostrils  to  be  in  the 
horizontal  rather  than  the  vertical  meridian.  The  correction  ot 
this  condition  is  very  easy  by  taking  a  section  of  the  rib  which  con- 
tains both  bone  and  cartilage.  The  bony  portion  comes  in  contact 
with  the  floor  of  the  nose  at  the  rostrum,  thus  getting  bony  union. 

3.  Cleft-Palate  and  Harelip  Operation.  This  is  such  a  very  large 
subject  that  a  paper  taking  full  time  limit  would  not  be  too  much. 
I  shall,  however,  confine  my  remarks  to  conclusion  that  I  have  ar- 
rived in  the  ultimate  results  of  the  cases  that  I  have  had. 


22  BECK  :     PRESENT  STATUS  OF   PLASTIC  SURGERY. 

1.  The  earlier  that  I  had  the  infant  to  operate  the  better  the 
results. 

2.  Always  do  both  lip,  hard  and  soft  palate  the  same  time,  eveii 
though  the  hard  palate  may  require  another  and  another  operation. 

3.  In  bringing  the  premaxillae  in  apposition  it  is  of  great  impor- 
tance not  to  penetrate  with  all  kinds  of  awls,  needles  and  wires,  this 
destroying  the  follicles,  arresting  the  development  of  the  jaw  and 
loss  of  permanent  incisor  teeth. 

4.  Great  effort  is  to  be  made  to  make  both  nostrils  similar  as 
well  as  avoiding  dimpling  or  puckering  of  the  lip  at  the  muco- 
cutaneous junction. 

5.  Most  of  my  failures  of  nonunion  of  soft  and  hard  palate  I 
believe  were  due  to  lack  of  freshening  of  margins  of  the  cleft  as 
well  as  not  sufficient  laxity  of  the  dissected  mucous  membrane.  In 
small  perforations  of  the  hard  palate  which  have  had  several  opera- 
tions, having  as  a  result  considerable  scarring  I  have  succeeded  in 
bringing  down  the  inferior  turbinated  body  and  closing  it. 

d.  Cosmetics:  There  are  type  of  deformities  or  malformations 
about  the  head  that  are  borderline  cases,  and  should  receive  our 
most  careful  and  expert  attention.  I  have  reference  to  congenital 
malformations  as  a  large  hump  nose,  saddle  nose,  extreme  bulbous 
tip,  extreme  small  or  large  nostrils,  short  upper  lip,  massive  hanging 
lower  lip,  deformed  ears,  etc.  Many  of  these  patients  have  talents 
and  opportunities  in  public  or  social  life,  but  keep  out  of  it  on  ac- 
count of  being  sensitive  or  so  handicapped  as  not  to  obtain  positions 
which  they  otherwise  would. 

e.  Psychic  or.  Imaginary.  This  form  of  deformity  or  malforma- 
tion is  probably  more  frequently  met  with  than  medical  men  have 
any  idea,  simply  because  most  of  these  unfortunate  mental  cases 
fall  into  or  are  forced  upon  the  "quack"  beauty  specialist.  I  mean 
they  are  forced  upon  them  by  the  regular  physician  and  surgeon 
who  recognizes  the  patient  to  be  a  neurotic  or  mental  case,  refuses 
to  operate  upon  them.  These  patients  are  the  most  difficult  to 
handle,  no  matter  from  what  standpoint  considered.  It  is  the  duty 
of  every  physician  and  surgeon  to  try  and  argue  with  them,  to  con- 
vince them  that  correction  is  unnecessary.  Only  in  a  small  minority 
will  one  succeed.  It  may  be  well  for  him  to  show  the  patient  some 
of  the  bad  results  that  have  been  obtained  at  the  hands  of  the  quack, 
such  as  parafinomas,  etc.  In  this  connection  I  wish  to  call  atten- 
tion to  a  horrible  case  of  parafinoma  recently  coming  under  my 


buck:    present  status  01;"  plastic  surgery. 


23 


care  and  in  which  I  believe  I  made  a  valuable  discovery  as  to  the 
treatment  of  this  terrible  condition. 

Miss  N.  Apparently  had  nothing  the  matter  with  her  nose ;  Fig. 
X.I,  went  to  some  doctors  in  Minneapolis  requesting  to  have  her  nose 
operated  for  some  imaginary  deformity.  He  refused,  so  she  fol- 
lowed the  alluring  advertisements  of  a  Chicago  Charlatan,  beauty 
doctor,  who  injected  her  with  paraffin.  There  resulted  a  typical 
parafinoma,  causing  the  girl  mental  and  physical  pain.  Fig.  XII 
shows  how  she  looked.     In  order  to  study  the  histologic  and  chem- 


Fig.  XI. 


ical  change  of  the  tissue,  I  excised  a  piece  from  the  center  where 
there  is  seen  a  scar.  Fig  XII.  Leaving  the  cut  surface  covered  only 
with  a  thin  layer  of  gauze,  I  noticed  that  from  the  margins  there 
was  an  outpouring  of  a  thick  whitish  substance  which  proved  to  be 
paraffin,  relieving  the  pain  and  making  the  tissues  much  softer. 
Whether  the  skin  will  recover  so  as  to  be  able  to  do  a  minor  opera- 
tion or  whether  the  entire  nasal  form  work  will  have  to  be  deco- 
rated as  in  rhinophema  I  am  not  able  to  say  at  this  time. 

While  the  open  treatment  to  the  parafinoma  was  beneficial  in 
that  considerable  amount  of  the  parafine  escaped,  il"  was  such  a 
slow  process  that  I  decided  to  operate  upon  her.     Under  general 


24 


BECK  :     PRESENT   STATUS   OF   PEASTIC   SURGERY. 


Fig.  XII. 


Fig.  XIII. 


beck:    present  status  oe  plastic  surgery. 


35 


Pig.   XIV.      Paraffinoma. 


Fig-.  XV.     (High  Power)  Paraffinoma. 


26 


beck:    prese;nt  status  of  plastic  surgery. 


anesthesia  (local  being  impossible,  owing  to  the  great  pain  in  even 
inserting  the  hypodermic  needle)  the  skin  about  the  nose  not  in- 
volved in  the  parafinoma  was  dissected  and  the  masses  of  the  tumor 
resected,  Fig.  XIV,  and  subjected  to  microscopic  examination.  Fig. 
XV.  The  tip  of  the  nose  which  contained  very  little  parafin  was, 
however,  much  changed  by  a  rhinophemic  appearance.  The 
venules  were  much  dilated  and  increased  in  number.  To  destroy 
them,  I  applied  25  mm.  of  radium  by  means  of  needles,  which  were 
left  in  for  eight  hours  at  two  different  periods.  Fig.  XVI  shows 
the  case  as  it  appears  now.      Some  time  later  I  intend  to   do  a 


Fig.   XVI. 


rhinoplastic   operation  to  cover  the   defect  at  the   dorsum   of   the 
nose. 

As  to  being  satisfied  with  the  cosmetic  result  it  is  practically 
unheard  of,  the  patient  asks  for  further  correction  even  if  it  is 
ever  so  little.  Recently  there  had  come  to  me  a  case  that  is  so 
important  in  the  discussion  of  my  subject  that  I  will  ask  your 
indulgence  to  listen  to  what  may  be  called  idle  gossip.  Important 
because  work  done  by  two  of  our  prominent  oto-laryngologists 
and   one   general    surgeon   prominent   in   this    line    of    work   have 


bi;ck:   present  status  oif  plastic  surgery.  27 

allowed  themselves  to  be  coaxed  into  operating  one  of  these  poor 
rich  creatures,  to  their  detriment,  the  patient  and  science.  Mrs. 
X,  about  35  years  of  age,  having  one  child,  all  the  comforts  of  a 
home,  decided  that  now  the  tim_e  has  arrived  when  she  must  have 
something  done  to  her  nose,  particularly  the  point  must  be  more 
prominent.  She  actually  shuns  the  society  of  her  friends,  being 
so  conscious  of  her  deformtiy.  A  photograph  shown  to  me  of  her 
appearance  at  that  time  shows  a  well  proportioned  nose  and  face. 
Traveling  very  far  she  reaches  the  doctor  with  the  reputation  (for 
she  will  never  consult  a  charlatan  or  advertising  quack)  who  tells 
her  that  she  does  not  need  the  operation  and  she  leaves  him  satisfied 
and  contented  to  leave  well  enough  alone.  The  same  day,  how- 
ever, the  specialist  has  her  notihed  that  all  is  prepared  for  her 
operation  for  the  next  morning.  Greatly  surprised  she  declares 
that  she  will  now  abide  by  the  doctor's  advice  not  to  be  operated 
upon,  whereupon  the  doctor  telephones  himself  stating  that  she 
had  better  have  it  done  for  she  will  never  rest  until  it  is  done. 
Going  to  the  doctor's  office  she  was  operated  under  local  anesthesia 
in  a  sitting  posture.  The  doctor  took  something  out  of  the  inside 
of  her  nose  and  put  it  over  the  bridge,  right  under  the  skin.  This 
caused  a  bad  hump  and  she  was  much  displeased  as  well  as  en- 
raged at  the  enormous  fee  demanded.  Returning  back  to  her 
home  she  was  much  distracted  over  her  appearance,  consulted  an 
oto-laryngologist  who  also  did  some  work  in  this  line.  This  gentle- 
man resected  a  piece  of  rib  which  fractured  into  three  parts  caus- 
ing an  empyema  for  which  she  was  twice  operated.  The  transplant 
into  the  side  of  her  nose  (alae)  made  things  much  worse  and  she 
was  now  in  a  horrible  condition  (all  these  are  exact  expressions 
of  patient  as  taken  down  by  stenographer).  In  due  time  she  had 
heard  of  another  great  man,  this  time  general  surgeon,  who,  ac- 
cording to  medical  publications,  could  help  her,  so  she  again  travels 
far  to  have  the  real  work  done.  She  had  also  received  informa- 
tion that  in  the  vicinity  of  this  general  surgeon  there  were  two 
other  oto-laryngologists  that  had  reputations  as  plastic  surgeons, 
so  she  consulted  them  also ;  however,  neither  one  of  these  would 
give  her  any  satisfaction.  Consequently  she  was  operated  upon  by 
this  general  surgeon  (specialist  in  plastics)  who  resected  a  piece  of 
rib  on  the  opposite  side  of  chest  and  planted  a  strip  over  the  bridge 
of  the  nose,  through  an  external  incision  at  the  root  of  the  nose. 
He  really  made  a  prominent  tip  and  she  thought  now  that  she 
would  be  satisfied.     Alas,  not  so,  the  sides  of  the  nose  were  now 


28  beck:   present  status  oe  plastic  surgery. 

very  unsightly  and  caused  her  whole  facial  expression  to  change 
to  an  abnormal  one.  Besides,  this  strip  that  the  last  doctor  put  in 
was  so  close  under  the  skin  at  the  tip  as  to  make  it  red  and 
painful,  also  fearing  it  might  push  through. 

This  threatening  ulceration  of  the  transplant,  caused  her  family 
physician  to  write  to  me  about  the  case  in  detail  and  asked  me  to 
take  charge.  Knowing  the  type  of  these  patients,  I  discouraged  him 
to  send  her  on  such  a  great  distance,  but  she  appeared  nevertheless. 
I  found  a  highly  cultured  lady,  absolutely  normal  in  every  way, 
mentally  and  physically,  now  very  sorry  as  to  what  she  had  done 
and  made  the  request  that  she  wished  she  could  have  her  nose 
as  it  was  before  anything  had  been  done. 

Examination  showed  the  transplant  protruding  at  the  tip  of  the 
nose,  being  covered  by  a  thin  layer  of  epithelium  and  surrounded 
by  a  red  and  painful  area.  I  condescended  to  remove  the  trans- 
plant and  at  the  same  time  implant  some  fat  in  the  tip  of  the  nose, 
to  prevent  subsequent  shrinkage.  This  was  accomplished  without 
any  difficulty  by  making  a  small  incision  in  the  colomella,  that  left 
no  visible  scar.  The  patient  left  very  much  happier  than  she  came, 
the  operation  having  prevented  an  ulceration  with  possible  second- 
ary infection  and  a  disastrous  result.  That  the  patient  will  not  be 
satisfied  with  the  cosmetic  result,  there  is  not  much  doubt  in  my 
mind,  but  the  lesson  she  has  learned  should  be  a  warning  to  others 
wanting  such  work  done,  or  to  the  surgeon  condescending  to  per- 
form such  operation.  As  stated  before  there  is  a  very  sharp  line 
of  differentiation  between  real  cosmetic  cases  and  such  as  these 
last  two  illustrated. 

2551  N.  Clark  St. 


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